Common Contracts
2 similar Health Savings Account Custodial Agreement contracts
HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENTHealth Savings Account Custodial Agreement • January 31st, 2005
The account holder whose name appears on the attached Application ("Depositor") is establishing a Health Savings Account ("HSA") under Section 223(a) of the Internal Revenue Code ("Code") exclusively for the purpose of paying or reimbursing qualified medical expenses of the Depositor and his or her spouse and dependents. The Depositor has assigned to the custodial account the sum indicated on the Application. The Depositor represents that, unless this account is used solely to make rollover contributions, he or she is eligible to contribute to this HSA; specifically, that he or she: (1) is (or as of the effective date as set forth in the Application will be) covered under a high deductible health plan ("HDHP"); is not also covered by any other health plan that is not an HDHP (with certain exceptions for plans providing preventative care and limited types of permitted insurance and permitted coverage); (3) is not enrolled in Medicare; and (4) cannot be claimed as a dependent on another
HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENTHealth Savings Account Custodial Agreement • November 23rd, 2004
The account holder whose name appears on the attached Application ("Depositor") is establishing a Health Savings Account ("HSA") under Section 223(a) of the Internal Revenue Code ("Code") exclusively for the purpose of paying or reimbursing qualified medical expenses of the Depositor and his or her spouse and dependents. The Depositor has assigned to the custodial account the sum indicated on the Application. The Depositor represents that, unless this account is used solely to make rollover contributions, he or she is eligible to contribute to this HSA; specifically, that he or she: (1) is (or as of the effective date as set forth in the Application will be) covered under a high deductible health plan ("HDHP"); is not also covered by any other health plan that is not an HDHP (with certain exceptions for plans providing preventative care and limited types of permitted insurance and permitted coverage); (3) is not enrolled in Medicare; and (4) cannot be claimed as a dependent on another
